Expanded indications for ultrasound-guided thrombin injection of pseudoaneurysms.

PURPOSE: We previously reported preliminary data on a new procedure that we developed for the treatment of femoral pseudoaneurysms after catheterization. This study presents our current results of percutaneous ultrasound-guided thrombin injection for treating pseudoaneurysms that arise from various locations and causes. METHODS: Between February 1996 and May 1999, we performed thrombin injection of 83 pseudoaneurysms in 82 patients. There were 74 femoral pseudoaneurysms: 60 from cardiac catheterization (36 interventional), seven from peripheral arteriography (four interventional), five from intra-aortic balloon pumps, and two from dialysis catheters. There were nine other pseudoaneurysms: five brachial (two cardiac catheterization, two gunshot wounds, one after removal of an infected arteriovenous graft), one subclavian (central venous catheter insertion), one radial (arterial line), and one distal superficial femoral and one posterior tibial (both after blunt trauma). Twenty-nine pseudo-aneurysms were injected while on therapeutic anticoagulation. Patients underwent repeat ultrasound examination within 5 days and after 4 weeks. RESULTS: Eighty-two of 83 pseudoaneurysms had initial successful treatment by this technique, including 28 of 29 in patients who were undergoing anticoagulation therapy. The only complication was thrombosis of a distal brachial artery, which resolved spontaneously. There were early recurrences in seven patients: four patients underwent successful reinjection; reinjection failed in two patients, who underwent surgical repair; and one patient had spontaneous thrombosis on follow-up. After 4 weeks, ultrasound examinations were completely normal or showed some residual hematoma, and there were no recurrent pseudoaneurysms. CONCLUSION: Ultrasound-guided thrombin injection of pseudoaneurysms has excellent results, which support its widespread use as the primary treatment for this common problem.

Patterns and distribution of isolated calf deep vein thrombosis.

PURPOSE: In the search for calf deep vein thrombosis (DVT) with color-flow duplex scanning (CFDS), most vascular laboratories investigate only the posterior tibial and peroneal veins. Few laboratories assess the soleal and gastrocnemial veins. This study was designed to determine the patterns and distribution of isolated calf DVT, including the soleal and gastrocnemial veins. METHODS: In the last 3 years, 5250 patients (mean age, 66 +/- 15 years; range, 22 to 93 years) were referred to the vascular laboratory for clinical suspicion of DVT and underwent examination with CFDS. All superficial and deep named veins, excluding the anterior tibial from groin to ankle, were imaged. Of the deep veins in the calf, the peroneal, the posterior tibial, the gastrocnemial, and the soleal veins were examined throughout their length. RESULTS: DVT was detected in 14% of the patients. Isolated calf DVT was detected in 282 limbs of 251 patients (4.8%). No significant difference was noted for the sex (114 men vs 137 women; P =.15) or the limb preference (145 left vs 137 right; P =.5). The peroneal veins were most frequently involved, with 115 limbs (41%) affected. The soleal veins were involved in 109 limbs (39%), followed by the posterior tibial in 105 limbs (37%) and the gastrocnemial in 79 limbs (29%). Thrombus in the soleal vein alone was found in 57 limbs (20%), in the gastrocnemial in 48 limbs (17%), in the peroneal in 41 limbs (15%), and in the posterior tibial vein in 35 limbs (12%). Thrombus confined to a single or paired vein was found in 181 limbs (64%). Thrombus involving two different veins (27%) was the second most frequent pattern, and thrombus in three (7%) or four (1.4%) different veins was less prevalent. Isolated thrombosis in veins not routinely investigated was found in 113 limbs (40%; soleal, n = 57; gastrocnemial, n = 48; soleal + gastrocnemial, n = 8). Multifocal origin of thrombosis, defined as thrombi in two different veins that do not anatomically communicate, was identified in 63 limbs (22%). CONCLUSION: Forty percent of the patients with acute isolated calf DVT would be judged to have normal CFDS examination results if the muscular veins in the calf were not imaged. Multifocal origin of thrombosis was found in 22% of the involved limbs. The prevalence of thrombosis in any calf vein either alone or in combination is comparable. Accordingly, the soleal and gastrocnemial veins should be examined routinely.